Send Us the Client’s Information by Fax

We maintain a secure fax to receive client information.

Send referral information to 414-434-1824

What should you include?

  1. The easiest solution is to print out our forms. If the client is able to do so at your office, have the client complete these forms:
    CLIENT REGISTRATION FORM

    CONSENT TO TREATMENT

    FAMILY HISTORY or CHILD HISTORY

    HIPAA PRIVACY NOTICE

    AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION

  2. If the client will take those forms to fill out later, at least complete the DISCLOSURE form listing your company on line one and your own contact information on line two of the section labeled “By/To.” Faxing that to us will enable us to share information with you.

  3. It will help get therapy started if we have a fax of both sides of the insurance card.
    NOTE: If the client has Title 19, Medicaid, or Badgercare, we just need the client’s social security number, not the Forward Card.

  4. With the client’s permission on a DISCLOSURE form, please fax any reports or information you may have or a summary of the data, concerns, and goals you may have.

Our secure fax number is: 414-434-1824

You’ve made an important decision to get help for your client.

Our goal is to get therapy
scheduled and started as soon as possible.
We hope to make this important step go as easily as we can.


Brown Deer Office: (414) 540-2170
Waukesha Office: (262) 446-9981

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